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Pregnant (Again) and Poor

Nahomie Nercure, 30, with some of her nine children in front of a her shack in the Haitian capital, Port au Prince. Credit
Nicholas D. Kristof/The New York Times

PORT-AU-PRINCE, Haiti

For all the American and international efforts to fight global poverty, one thing is clear: Those efforts won’t get far as long as women like Nahomie Nercure continue to have 10 children.

Global family-planning efforts have stalled over the last couple of decades, and Nahomie is emblematic both of the lost momentum and of the poverty that results. She is an intelligent 30-year-old woman who wanted only two children, yet now she is eight months pregnant with her 10th.

As we walked through Cité Soleil, the Haitian slum where she lives, her elementary-school-age children ran stark naked around her. The $6-a-month rental shack that they live in — four sleep on the bed, six on the floor beside it — has no food of any kind in it. The family has difficulty paying the fees to keep the children in school.

There’s simply no way to elevate Nahomie’s family, and millions like it around the world, unless we help such women have fewer children. And yet family-planning programs have been shorn of resources and glamour for a generation now.

Nahomie is one of 200 million women worldwide who, according to United Nations estimates, have what demographers call an “unmet need” for safe and effective contraception. That is, they don’t want to get pregnant but don’t use a modern form of family planning.

The push for contraception was at the center of development efforts in the 1960s and 1970s, but then waned. In part, it was tarnished by its own zealotry, including coercion in China and India. Another reason was abortion politics, which led to a cutoff in American financing for the United Nations Population Fund — even though the upshot was more unwanted pregnancies and more abortions.

Photo

Nicholas D. KristofCredit
Fred R. Conrad/The New York Times

In addition, family planning turned out to be harder than many enthusiasts had expected, for it requires far more than condoms or the pill. Haiti has family-planning clinics, spending on contraception is fairly high, and women say they want fewer children — yet only one-quarter of Haitian women use contraceptives.

Nahomie’s story helps explain the enigma. She tried injectables, but she says they caused excess bleeding that frightened her. The clinic had little counseling to explain and reassure her, so she stopped after nine months.

A sexually transmitted infection at the time meant that she couldn’t use an IUD just then, and a doctor told her that the pill would be inappropriate because she has vascular problems. Reluctant to return to a clinic that seemed scornful of poor women, she drifted along with nothing.

A couple of babies later, her first husband left her, and her next husband wanted to have children with her, so she acquiesced. A few children later, she began to push back, but in Haiti’s social structure she felt she had to accede to her husband’s whims. “I asked to use condoms,” Nahomie said, “but he refused.” Last fall, shortly after she became pregnant with her 10th child, her husband ran off.

A book published a few years ago, “Reproducing Inequities,” notes that we are, painstakingly, learning what does work. The effective strategies go beyond the contraceptive devices themselves to include better counseling, more dignity for women in clinics, a greater choice of methods that are completely free — and a broad effort to raise the status of women.

The best way to elevate women, by far, is to educate girls and to give them opportunities to earn income through micro-loans, factory jobs or vocational training. It is sometimes said that the best contraceptive isn’t the pill or the IUD, but education for girls.

(A side note: Whenever I write about efforts to save children from malaria or diarrhea, I get cynical letters from neo-Malthusians who argue that saving children’s lives is pointless until birthrates drop. That’s incorrect. There’s abundant evidence that when parents are confident that their children will live, they will have fewer and invest more in each of them.)

In any case, the mounting academic evidence underscores what is intuitively obvious in Haiti: unless family planning is more successful in poor countries, they won’t be able to overcome poverty. “There’s no other way,” says Tania Patriota, the representative of the United Nations Population Fund in Haiti. “It’s indispensable.”

President Obama has already lifted the ban on aid for the Population Fund, and we now have an opportunity to lead a global effort to regain lost momentum for family planning. And while Nahomie’s story shows that this won’t be easy, it also underscores that there’s simply no alternative.